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Elder v. Berryhill

United States District Court, E.D. Missouri, Eastern Division

January 2, 2018

MICHAEL ELDER, JR., Plaintiff,
v.
NANCY A. BERRYHILL, Acting Commissioner of Social Security, Defendant.

          MEMORANDUM

          DAVID D. NOCE, UNITED STATES MAGISTRATE JUDGE

         This action is before the court for judicial review of the final decision of the defendant Commissioner of Social Security denying the application of plaintiff Michael Elder, Jr., for supplemental security income benefits (SSI) under Title XVI of the Social Security Act, 42 U.S.C. §§ 1381-1385. The parties have consented to the exercise of plenary authority by the undersigned United States Magistrate Judge pursuant to 28 U.S.C. § 636(c). For the reasons set forth below, the final decision of the Commissioner is reversed and remanded for further consideration.

         I. BACKGROUND

         Plaintiff was born in 1968 and was 47 years old at the time of his hearing. He filed his application on October 31, 2013, alleging a September 21, 2000 onset date. (Tr. 153-58). In his Disability Report, he alleged disability due to nerve damage with pain in the left arm, left and right knee pain, left hip pain, emotional problems, and major depression. (Tr. at 210). His application was denied, and he requested a hearing before an ALJ. (Tr. 1-6, 14-16, 98-102).

         On January 7, 2016, following a hearing, an ALJ found that plaintiff was not disabled as defined in the Act. (Tr. 17-38). The Appeals Council denied his request for review. (Tr. 1-3). Thus, the decision of the ALJ stands as the final decision of the Commissioner.

         II. ADMINISTRATIVE RECORD

         Plaintiff has an extensive medical history. The court summarizes plaintiff's medical records to the extent relevant to this appeal.

         On May 21, 2013, plaintiff was treated in the emergency room after being hit in the leg with an ax handle and was diagnosed with a contusion. His left knee was placed in an immobilizer and he was prescribed hydrocodone-acetaminophen. (Tr. at 236, 240).

         On September 17, 2013, plaintiff was seen in the emergency room with thoughts of killing his mother and step-father. He reported increased thoughts of suicide over the previous several weeks. Plaintiff reported symptoms of depression, increased irritability, difficulty with concentration and focus, and difficulty sleeping. His urine drug screen was positive for marijuana and his blood alcohol level was 0.2. Plaintiff improved with lithium. He was discharged with a diagnosis of major depressive disorder, and prescribed Celexa, an anti-depressant; trazodone, for insomnia; and lithium, for mood stability. (Tr. at 261-63

         Plaintiff was hospitalized at Phelps County Regional Medical Center December 8-16, 2013 after overdosing on lithium and vodka. He reported planning to cut his wrists. He was diagnosed with depression, alcohol use disorder, marijuana use disorder, personality disorder, not otherwise specified, and substance abuse. His GAF score was “About 60.” Plaintiff participated in group therapy and was much improved and stable upon discharge. Because he did not have an income or housing, he was discharged to a shelter to follow up at Pathways Behavioral Health (Pathways). (Tr. at 275-79).

         On February 6, 2014, plaintiff underwent a psychological examination by Thomas J. Spencer, Psy. D., to determine Medicaid eligibility. He reported a history of nerve damage in his left arm, as well as depression with symptoms of lack of energy, isolating himself, difficulty sleeping, racing thoughts, and inability to focus. He also reported abusing alcohol. On exam, Dr. Spencer noted plaintiff had flat speech and restricted affect. He diagnosed alcohol dependence in early remission, bipolar disorder, and polysubstance dependence in sustained remission. Dr. Spencer assessed a GAF score of 50 to 55 and opined that plaintiff's mental illness interfered with his ability to engage in employment. (Tr. at 314-18).

         On May 7, 2014, plaintiff underwent another Medicaid evaluation. He reported experiencing low back pain, left knee pain, and left arm pain. Plaintiff reported that he had been involved in a work accident in 2000, sustaining a cut to his arm and nerve damage. He had also been attacked with an ax handle in 2013. Upon exam, he had decreased range of motion of the left shoulder, elbow, hand and wrist, as well as of the knees and lumbar back. He was diagnosed with chronic back pain, left knee pain, and permanent nerve damage to the left upper arm secondary to laceration. The examiner found plaintiff had a loss of normal function of the left hand as well as decreased strength of the left arm. (Tr. at 330-33).

         On July 8, 2014, plaintiff began treatment at Pathways Behavioral Health. On July 11, 2014, he saw Bhaskar Gowda, M.D., a psychiatrist. Plaintiff reported his history of depression and substance abuse. He said that he felt he had been doing well until he injured his hand and became unable to work when he started feeling depressed, hopeless, and helpless. Plaintiff reported experiencing symptoms of constant worry, edginess, and difficulty sleeping. Dr. Gowda diagnosed major depressive disorder and assessed a GAF score of 50. He started plaintiff on Seroquel, an antipsychotic medication. (Tr. at 764-72).

         On August 1, 2014, plaintiff reported that he was no longer drinking alcohol, although he continued to feel depressed and hopeless. He also reported experiencing restlessness while on Seroquel, and Dr. Gowda therefore decreased his dosage. (Tr. at 754-55). Plaintiff continued to report symptoms of anxiety, difficulty concentrating, anger, depression, difficulty ...


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